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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 9. 2018 <br />Jeff Hudak <br />Department Central Services <br />BPW Date March 27, 2018 Phone Extension 574-235-9316 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Clara McDaniels <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® Michael Schmidt <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEIWBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of ❑ <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O &PCANo. <br />� <br />❑ Traffic Control <br />® Req. to Advertise <br />ROuireci Information <br />❑ PCA <br />U Title Sheet <br />❑ Yes ❑ No ❑ If Yes, A roved b Purchasin <br />n MBE n WBE <br />❑ No ❑ Yes Name of Company <br />Spec H -- One (1) or more 2018 or Newer One Ton Four Wheel <br />Drive Pickup Truck Includin Animal Trans ort Module <br />2018 Animal Control Capital Principal 600-1207-415-4309 <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />I ncrease $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />o/a <br />Dispersal After Approval <br />_Jeff Hudak & Jen Gabel <br />Ron O'Connor, Randy Wilkerson <br />